Why CAUSE is Different From the Other Health Plans

Because the CAUSE approach is implemented over 15 years, it allows time for the training of enough
primary care physicians to provide care to the newly insured. Having primary care
physicians for all will enhance prevention and enhance coordination of care that the
modified Medicare Parts 1 and 2 will offer. Therefore, patients are given more than
an insurance card, they are given REAL access to good care.

CAUSE is affordable. The costs for transitioning to universal access to basic health care
is spread over 15 years. We begin by insuring children with Medicare 1 and 2, yet
allow parents and the employers the opportunity to purchase private alternatives.
The funding source, such as a financial transaction tax, provides an immediate means
of paying for this first phase. The long implementation also gives time necessary
for the cost saving aspects of the plan to be realized. These include practicing evidenced
based medicine, health information technology, promoting health and disease prevention
and lowering administrative costs. In years 6-10 of implementation, based on cost
information gleaned from the previous 5 years, state boards can be made to work within
budgets.

Career choice is no longer dependent on maintaining health benefits, and this helps
employees.

The delivery of care to patients is improved by letting them go to their own physician
for care whether injured at work, home, or in a car.

CAUSE provides universal coverage by building on a Medicare system that is currently operational,
with low administrative costs, and high acceptability among the U.S. population.It
is not a single payer plan. It preserves a role for the private insurance companies
by allowing individuals and employers to buy supplemental private policies to cover
deductibles and other out of pocket costs for Medicare 1 and 2. There is also a choice
for patients to buy a supplemental policy for services not covered by CAUSE. Individuals
and employers can also purchase a private alternative to Medicare for All even when
fully implemented.

CAUSE addresses the impending financial crisis of Medicare by containing cost increases
through budgeting, improving prevention of disease and coordination of care with a
strong primary care delivery system, broadening the pool of patients paying into and
using the system, and by changing fees and payments to support services proven to
make people healthier.

CAUSE addresses variations across the country in health care resources and access to quality
care by tying Medcaid reimbursement rates to Medicare and increasing Federal Medicaid
matching to the poorest sub-state regions.

Insurance Market Reforms

Reforms will be made to the insurance market in three ways. First, the qualifying
private plans would not be able to deny children coverage due to health status. Private
wraparound plans for adults who buy into the CAUSE plan Part B would not be able to deny coverage due to health status. Lastly, community-based
premiums will be charged for children in wraparound plans. This will make more readily
available a higher quality of insurance, especially to those most in need of high-quality,
private health care plans.

An important part of continuity of care and promotion of health is ensuring that patients
stay on their prescribed medications even when they change insurance coverage. CAUSE will, without exception, cover a patient’s medical regimen even when the patient
changes his or her health care insurance plan or coverage. The choice of medical regimen
will be determined by the physician and patient.

Administrative Modifications

The CAUSE approach will be administered through a national health board that serves as a center
for medical effectiveness. It will consist of clinicians, researchers, hospital administrators,
business community members, health care managers and economists, nurses, health insurance
and managed care organization representatives, consumer groups, patient representatives,
public health experts, pharmacists versed on the effectiveness of medications and
the costs of drug development, and health policy scholars. Providing a large range
of experts will guarantee that all sides of every health issue are looked at carefully
and that the best solution or solutions are always made. National health board members
will be chosen by the president and confirmed by the Senate for at least 10-year terms
so as to exceed the tenure of any single presidential administration and ensure continuity
in policy.

There will be many other important functions of the national health board. One will
be to help produce and publicize information that promotes the adoption of clinically
based medicine and establishes incentives for best practices. Targeted funding will
be provided through the Agency for Healthcare Research and Quality (AHRQ) and the
National Institutes of Health (NIH) for research which will evaluate new and existing
medical treatments and devices on their effectiveness in making our society healthier.
Researchers will include health policy experts at academic centers, independent research
staffs, and private pharmaceutical or biotechnology companies. A team of research
analysts employed by the board will investigate the cost-effectiveness and value of
certain medical tests and treatments. The team will also make recommendations regarding
what drugs and procedures ought to be covered based on demonstrated effectiveness.

Funding from the board will allow for hospitals and physicians to coordinate appropriate
pilot programs, while eliminating co-pays for those procedures or tests that are most
effective and increasing co-pays for treatment options found inconsistent with evidence-based
medical management. Funding would come from 0.05 percent of projected CAUSE spending from the Medicare Hospital Insurance Trust Fund, 0.05 percent of the projected
Medicaid spending from general revenues, and an assessment of 0.05 percent of private
insurance premiums. The national health board would also alter reimbursements for
physicians by increasing payments for services that result in better health outcomes
and have historically been poorly reimbursed, including but not limited to prevention,
diagnosis, coordination of care, and following evidenced-based medicine. It will also
reduce physician payments for procedures and tests that are not thought to improve
health outcomes or quality of life.

There will be at least one elected and appointed health board for each state; states
with larger populations could have sub-state regional elected and appointed health
boards to keep health care uniquely formed for the specific needs of any given population
or special needs due to region. Board membership selection would be designed to ensure
that all stakeholders are represented. This would allow the different health needs
and patient populations of each state and sub-state region to communicate needs and
policies to the national health board.

State and sub-state boards will monitor CAUSE costs and develop plans for increasing effectiveness and efficiency of CAUSE delivery. The national health board and state health boards will also work with the
present Medicare intermediaries in administering the new approach. Public health issues,
credentialing and licensure, formularies, malpractice, and safety forums remain under
state jurisdiction. State and sub-state boards will also provide a public forum for
debate and public input on issues such as ethics, value purchasing, and coverage.

Modifications to Current Medicare Healthcare Delivery

Much of the present Medicare and health care delivery framework will remain intact.
Some adjustments will be made to areas such as payments. Payments to providers will
be a combination of fee-for-service, salary, and capitation to the variety of health
delivery systems that we presently have. Fee schedules will be altered to pay more
for cognitive services and procedures shown to be of benefit, and less for procedures
deemed marginally useful for enhancement of health. Payment for identical services
will be uniform regardless of physician specialty. The Federal Medical Assistance
Program (FMAP) will be changed to provide supplemental federal funding to large sub-state
areas with populations of 500,000 people or more that are poorer than the state averages.
This will successfully increase access to health care and enhance the quality of care.
Fee-for-service payments for procedures and services should be nationally uniform,
with adjustments for differences in cost of living. Additional adjustments based on
population health and health care system features will be made into fee-for-service
rates. Similar factors will be considered in establishing local area costs as a basis
for negotiating organized delivery system rates.

Modifications to Promote Health

The educational system as well as public policy will be utilized to encourage healthy
habits in schools and neighborhoods. This will work in prevention, helping attend
to habits that contribute to poor health, which in turn will create a generally healthier
nation. Ideas like nutrition becoming a part of the elementary and secondary school
curriculum, junk food and soda being banned in schools, and having education on lifelong
physical activity implemented in schools would help promote prevention from an early
age.

To promote health, the reform will encourage utilizing the employer/employee connection
in health care. Tax credits will be given to employers to offer programs that enhance
health of employees in areas such as exercise, weight loss, and healthy food options.
Good health practices such as blood sugar measurement, hemoglobin A1C, blood pressure,
cholesterol level, weight, body mass index, and smoking cessation will be rewarded.

If patients meet benchmarks, they could receive rebates or they could be eligible
for lower insurance premiums from employers or through CAUSE. The tax code would be amended to allow employees to use flexible spending accounts
for specified programs that reward good health practices. The Health Insurance Portability
and Accountability Act (HIPPA) would be amended to mandate that all insurance plans
are exempt from deductibles as preventive services. This would be recommended and
regulated by the national health board with input from the regional boards. To fund
such programs, the federal government will increase the federal excise tax on cigarettes
to $5.39, with a proportional increase in the taxes on other tobacco products.

To further promote health, primary care and care coordination will be strengthened.
Strengthening strategies will include offering financial incentives for medical school
graduates to enter primary care specialties and remuneration for cognitive services
will be increased relative to procedures. Quality and efficiency-based economic incentives
will be offered for physicians who provide patients a medical home as their primary
care physician. Additional providers will be trained to accommodate the repeal of
the freeze on postgraduate training programs. Training will be modified to encourage
primary care; incentives will be provided in the form of pay and a cut in medical
school expenses.

Establishment of Systems that Improve the Use of Information

A Health Information Technology (HIT) program will be promoted by CAUSE. This will consist of the federal government levying a 1 percent tax on private insurance
premiums and spending 1 percent of CAUSE expenditures for HIT. There could also be matching funds with the states to provide
capital assistance to providers as they begin to adopt the HIT program. Federal matching
funds with the states will help to develop health information exchange networks. Advancing
health information through technology will help health care providers provide the
best treatment possible in a more direct and efficient way.

Medical Mal-Practice Policies

CAUSE would require malpractice law reform nationally in order to reduce the costs of malpractice
insurance for providers. Under CAUSE, an individual who files a malpractice claim in state court should have the facts
of the case reviewed by a panel chosen in consultation with the state health boards
that consists of not less than one qualified medical expert, a physician whose specialty
is appropriate to the case, a community representative, and a legal expert. The panel
will review the facts of the case to verify that a malpractice claim exists. There
would be a presumption of reasonableness if the health care provider demonstrates
adherence to the accepted evidence-based and clinical practice guidelines established
by the national health board. Using the panel findings, the individual will have the
option to engage in non-binding mediation prior to filing an action in court. There
would be sanctions against attorneys who file frivolous malpractice claims in court.

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